Maximum Dose of Diazepam for Seizure Management
For status epilepticus in children, the maximum single dose of intravenous diazepam is 10 mg per dose, which may be repeated every 10-15 minutes up to a maximum total dose of 30 mg. 1, 2
Intravenous Dosing Protocol
Initial Dosing
- Administer 0.1-0.3 mg/kg IV every 5-10 minutes with a maximum of 10 mg per single dose 1
- Infuse over approximately 2 minutes to avoid pain at the IV site 1
- The FDA label specifies 5-10 mg initially for status epilepticus, repeatable at 10-15 minute intervals 2
Maximum Cumulative Dose
- Total maximum dose is 30 mg across all repeated administrations 2
- If seizures persist after reaching maximum dose, therapy may be repeated in 2-4 hours, though residual active metabolites may persist and require consideration 2
Age-Specific Pediatric Dosing
- Infants >30 days and children <5 years: 0.2-0.5 mg slowly every 2-5 minutes up to a maximum of 5 mg 2
- Children ≥5 years: 1 mg every 2-5 minutes up to a maximum of 10 mg 2
- Repeat in 2-4 hours if necessary 2
Alternative Routes When IV Access Unavailable
Rectal Administration
- Dose: 0.5 mg/kg up to 20 mg 1
- This route has erratic absorption and is less reliable than IV administration 1
- Should only be used when IV access cannot be established 1
Intramuscular Route
- IM administration is NOT recommended due to risk of tissue necrosis 1
- Other benzodiazepines (lorazepam, midazolam) are preferred if IM route is necessary 1
Critical Safety Considerations
Respiratory Monitoring
- Increased incidence of apnea occurs with rapid IV administration or when combined with other sedative agents 1
- Continuous oxygen saturation and respiratory effort monitoring is mandatory 1
- Be prepared to support ventilation immediately 1
Cardiovascular Effects
- Extreme caution required in patients with chronic lung disease or unstable cardiovascular status 2
- Hypotension may occur, particularly with rapid administration 2
Essential Follow-Up Management
Immediate Anticonvulsant Coverage
- Diazepam must be followed immediately by a long-acting anticonvulsant (phenytoin/fosphenytoin) because it is rapidly redistributed 1
- Seizures often recur within 15-20 minutes after diazepam administration 1
- Lorazepam may be preferred over diazepam due to prolonged duration of anticonvulsant activity 1
Reversal Agent Availability
- Flumazenil may reverse life-threatening respiratory depression 1
- Critical caveat: Flumazenil also counteracts anticonvulsant effects and may precipitate seizure recurrence 1
Common Pitfalls to Avoid
- Do not exceed 10 mg per single dose regardless of patient weight in adults 2
- Avoid rapid IV push—administer over 2 minutes minimum 1
- Never rely on diazepam alone without transitioning to maintenance anticonvulsant therapy 1
- Recognize that diazepam's effectiveness is limited (only 36% effective as monotherapy in one study) compared to midazolam (57.6% effective) 3